Charting by exception... - page 2
We have been given new daily flow sheets at work and are now supposed to "chart by exception." The entire assessment is supposed to be done by checks and we shouldn't need to write anything else in... Read More
Jun 9, '06when charting by excetion make sure you know the standard/ parametors to which you're charting to. ie. vital signs with in - / + 20% of 120/80, 60, 18 , 98.6 ect.
Jun 9, '06I really like this system and frankly have used it for years. Our sheets have a small list of checks on the side, and room for charting the entire rest of the page. It also has an area above that has "no changes at _____" so that it shows the patient was checked every two hours.
I do tend to write more in the nursing notes because I am days and lots of things happen (med surge), I will write when the MD visits and say "see order sheet", and typically with my first entry I will put down "will continue to follow plan of care and narative PRN". Which helps show I will follow the care plan and if nothing happened all day...well that PRN statement covers that" That is my CYA!